Citation Nr: 21064867 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 15-36 223 DATE: October 21, 2021 ORDER Entitlement to service connection for vision problems, to include bilateral cataracts, including as secondary to Parkinson's disease and exposure to Camp Lejeune Contaminated Water (CLCW), is denied. Entitlement to service connection for dry eye syndrome, secondary to Parkinson's disease, is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's vision problems, to include bilateral cataracts, are secondary to service-connected Parkinson's disease or are otherwise related to an in-service injury or disease, to include CLCW exposure. 2. Resolving reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that the Veteran's dry eye syndrome was caused by his service connected Parkinson's disease. CONCLUSIONS OF LAW 1. The criteria for service connection for vision problems, to include bilateral cataracts, including as secondary to Parkinson's disease and exposure to CLCW, have not been met. 38 U.S.C. §§ 1110, 1113, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for dry eye syndrome, secondary to Parkinson's disease, have been met. 38 U.S.C. §§ 1110, 1113, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1966 to January 1967 and from May 1970 to July 1972. This case is before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office that denied service connection for vision problems. In September 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the electronic claims file. The Board remanded the matter for further development in October 2018, July 2020, and June 2021. As an initial matter, review of the Veteran's VA treatment records indicate he has a current diagnosis of dry eye syndrome. Therefore, the Board has taken an expansive view of the Veteran's claim for vision problems and pursuant to Clemons the issues are recharacterized as shown above. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Now the matter is returned to the Board. Service Connection A veteran is entitled to VA disability compensation if there is disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection is also warranted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (b). Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to CLCW if a veteran, former reservist, or member of the National Guard shows: (1) that he or she served at Camp Lejeune for no less than 30 consecutive or nonconsecutive days between August 1, 1953 and December 31, 1987; (2) that he or she currently suffers from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309 (f); and (3) that the current disease manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f) (2020). This presumption may also be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. Diseases associated with exposure to contaminants in the water supply at Camp Lejeune, North Carolina if the Veteran served for at least 30 days are: (1) kidney cancer; (2) liver cancer, (3) non-hodgkin's lymphoma, (4) adult leukemia; (5) multiple myeloma; (6) Parkinson's disease; (7) aplastic anemia and other myelodysplastic syndromes; and (8) bladder cancer. 38 C.F.R. §§ 3.307(a)(7), 3.307(d). Notwithstanding the foregoing provisions regarding presumptive service connection for exposure to CLCW, a veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). For VA to deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App., at 54. Facts and Analysis The Veteran seeks service connection for vision problems. He contends that his eye disability is related to service, including as the result of CLCW exposure and due to his service-connected Parkinson's disease. The Board notes that the Veteran's exposure to CLCW has been conceded as the record confirms his service at Camp Lejeune. Also, the evidence of record shows the Veteran's current diagnosis includes dry eye syndrome and visual problems, including bilateral cataracts. However, as provided above, eye disabilities are not presumptively service-connected based on Camp Lejeune service. 38 C.F.R. §§ 3.307(a)(7), 3.307(d) (2020). Thus, the Board will examine whether the Veteran is entitled to direct or secondary service connection for dry eyes and visual problems, to include bilateral cataracts. The Veteran's service treatment records show he had impaired vision corrected to 20/20 with prescription lenses. See January 1967 separation examination. There is no evidence of an eye injury or treatment for an eye disease during his period of active duty service. The Veteran underwent a VA examination in February 2020 and the examiner provided an opinion on the matter. However, the February 2020 opinion was found to be inadequate in the July 2020 Board Remand and therefore not probative. In March 2021, additional VA medical opinions regarding the etiology of the Veteran's vision problems were obtained. Although the examiner opined vision problems were not related to service, the Board's June 2021 decision found the examiner failed to address an IOM report entitled "Review of VA Clinical Guidance for the Health Conditions Identified by the Camp Lejeune Legislation" that the Veteran submitted in support of his CLCW contention, as well as to provide a rationale for the conclusion that visual problems were not related to Parkinson's disease. As such, the matter was again remanded for a VA addendum medical opinion in June 2021. In June 2021, a VA medical examiner provided the diagnoses of bilateral cataract; dry eye syndrome, resolved; mildly increased intraocular pressure, left eye; and refractive error, including status post bilateral keratotomy. The examiner reviewed the evidentiary record, including the service treatment records, and the Camp Lejeune Legislation IOM report to determine the nature and etiology of the Veteran's condition. The June 2021VA examiner explained that the IOM report referred to deficits in contrast sensitivity and color discrimination that were unrelated to the Veteran's diagnoses. See June 2021 VA medical opinion, at 3. Bilateral cataracts and mildly increased intraocular left eye pressure were determined as secondary to aging. Bilateral dry eye syndrome was noted as a known complication of keratotomy, but also identified for having been diagnosed by the Veteran's VA ophthalmologist as consistent with Parkinson's disease. The examiner could not determine the etiology of the Veteran's refractive error from the evidence but noted that it was likely multifactorial. The examiner found no evidence in the scientific literature to suggest cataracts, dry eye syndrome, intraocular hypertension, and a decision to undergo radial keratotomy was caused by or related to volatile organic compound exposure. Notably, the examiner stated that factors affecting the Veteran's visual acuity included normal aging changes of the eye, mild cataract, history of radial keratotomy, Parkinson's disease effects, and possibly stroke residuals. Id. However, the examiner thereafter opined that given the body of current medical knowledge and the evidence of record, including the weak association of volatile organic compound exposure and eye/vision related conditions in the currently available literature and the Veteran's known risk factors, and his very brief period of exposure to volatile organic compounds at Camp Lejeune, the Veteran's vision problems were less likely as not caused by or a result of CLCW exposure. The June 2021 VA examiner did not provide an opinion on whether the Veteran's vision problems and/or eye diagnoses were due to Parkinson's disease. In July 2021 VA medical opinion, the same examiner who provided the March 2021 report opined that the Veteran's vision problems were less likely than not related to service. The examiner reviewed the medical record and determined cataracts were due to the natural aging process and stroke did not result in vision loss or visual field loss. Regarding the Veteran's claim for secondary service connection, the examiner opined that vision problems were less likely as not proximately due to or aggravated beyond the natural progression of the disability by his service connected Parkinson's disease. As rationale, the examiner provided there was no known link between Parkinson's and vision loss, as cataracts were due to natural aging. Moreover, the examiner provided that the record did not support progression. 1. Vision Problems, to include Bilateral Cataracts Under the circumstances of this case, the Board finds that service connection is not warranted for vision problems, to include bilateral cataracts, as secondary to Parkinson's disease, as well as due to exposure to CLCW is not warranted. Initially, the Board notes there is a current diagnosis of vision problems, to include bilateral cataracts. Thus, the first element of service connection in met. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Notably, the Veteran's service treatment records were negative for diagnosis of bilateral cataracts. There was impairment in visual acuity, corrected by lenses, but without evidence of injury or illness. Refractive errors of the eyes are considered a congenital or developmental abnormality, and as such, are not subject to service-connection. 38 C.F.R. § 3.303. The Board finds that the weight of the evidence is against a finding that the Veteran's current vision problems, to include bilateral cataracts, is etiologically related to his military service. Significantly, all medical opinions addressing the etiology of the claimed eye disability weigh against the claim. VA examiners in June 2021 and July 2021 specifically noted review of the evidentiary record and provided negative nexus opinions that indicated it was less likely than not that the Veteran's eye conditions were incurred in or caused by service, to include exposure to CLCW, as well as caused or aggravated by the Veteran's service connected Parkinson's disease. Specifically, the June 2021 VA examiner reviewed the IOM report and found no evidence in the scientific literature to suggest the Veteran's diagnoses were related to volatile organic compound exposure. Although the examiner appears to include Parkinson's disease as a factor affecting the Veteran's visual acuity, when read in context of the entire opinion, the report clearly excludes Parkinson's relationship to the Veteran's other eye diagnoses, except for dry eye syndrome. Moreover, the examiner only offered supporting rationale for the opinion that the Veteran's vision problems were less likely caused or the result of CLCW exposure. Also, the July 2021 VA examiner determined bilateral cataracts were due to natural aging, adding that there was no known link between Parkinson's disease and vision loss. The examiner also provided that the Veteran's records showed no evidence of progression to support aggravation. Thus, the examiner opined the current visual problems were less likely than not proximately due to or aggravated beyond its natural progression by the Veteran's service connected Parkinson's disease. None of the competent medical evidence of record refutes these conclusions, and the Veteran has not presented or identified any such existing medical evidence or opinion. Thus, the Board finds the June 2021 and July 2021 opinions to be persuasive. To the extent that the Veteran contends his current vision problems are related to service or to his service connected Parkinson's disease, this determination pertains to an internal medical process which extends beyond an immediately observable cause-and-effect relationship. Opinions of this type have been found to be beyond the competence of lay witnesses, as is the Veteran. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Given such, it cannot be stated that he is competent to provide a nexus statement. All in all, the Veteran's lay statements have been reviewed and considered. However, the Board finds that all the VA medical evidence and opinions taken together are highly probative as they are based on sufficient facts and data, a product of reliable principles and methods, and applied the principles and methods reliably to the facts of this case. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). Significantly, there is no contrary medical opinion. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine does not apply, and the claim for entitlement to service connection for vision problems, to include bilateral cataracts, as secondary to his service-connected Parkinson's disease, or otherwise related to an in-service injury or disease, to include CLCW exposure must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Dry Eye Syndrome First, the Board finds the Veteran had a current diagnoses of dry eye syndrome during the appeal period. Although the VA examiners noted the disability as resolved, VA medical treatment records show the Veteran with a diagnosis, problem list, and medication history that includes the disability. See e.g., September 10, 2019 Kerrville VA medical center (MC) medical treatment record and February 3, 2021 VAMC Kerrville VAMC active problem list. Thus, the first element of service connection is satisfied. As noted, the Veteran's service treatment records do not indicate treatment for an illness or injury to the eyes. With respect to secondary service connection, the Veteran's VA ophthalmologist diagnosed bilateral dry eye syndrome, left greater than right, as consistent with Parkinson's disease. The diagnosis was made during an in-person examination, and included a notation that the Veteran's records, to include Parkinson's, were reviewed. See September 10, 2019 Kerrville VAMC medical treatment record. As noted above, the June 2021 VA medical opinion indicated a diagnosis of dry eye syndrome, resolved. The examiner noted the disability was a known complication of radial keratotomy, but also recognized that dry eye syndrome was diagnosed by the Veteran's ophthalmologist as consistent with Parkinson's disease. Significantly, the June 2021 VA examiner did not offer an opinion on etiology of the Veteran's diagnosis of dry eye syndrome, in conjunction with the remarks concerning his possible risk factors. Based on above and resolving reasonable doubt in favor of the Veteran, entitlement to service connection for dry eye syndrome, as secondary to Parkinson's disease, is granted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Gipson, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.